Pediatric Heart Failure Guidelines
Heart Failure Medications
Dose Escalation and Approach to Heart Rate and Blood Pressure Management
Dosage of heart failure medications should be up titrated until the target dose is reached, side-
effects or symptoms occur (see medications for details at end of guideline). At each outpatient
visit with the heart failure team, cardiac medication should be assessed and up titrated as
necessary. Due to side effects, often only one medication is up titrated at each visit. The
attending physician may decide to up titrate more than one medication, or prioritize one over the
other if clinically warranted (e.g. tachycardia, hypertension, myocardial fibrosis, edema). The
general approach will to be initiate heart failure treatment with ACE-I and once optimized add
beta blockade, followed by aldosterone inhibition. However this can be altered based on
individual patient characteristics, disease state, side effect concerns or other patient factors.
The majority of anti-heart failure medications lower blood pressure and/or lower heart rate.
Concern for low blood pressure and/or low heart rate often lead to delays in dose escalation.
The general approach will be to continue to advance anti-heart failure medications as long as
the patient is asymptomatic (dizziness, syncope, lightheadedness, etc.) from hypotension or
bradycardia, or the degree of bradycardia/hypotension is severe enough to cause harm (end-
organ dysfunction, arrhythmias, syncope). The degree of bradycardia and hypotension will
depend upon each individual.
ACE-Inhibitors
ACE inhibitors are common first line medications used in the treatment of heart failure. Captopril
is usually used to initiate therapy if patient is hospitalized, otherwise Enalapril is the first line
ACE-I. Lisinopril is a daily dose and useful in older patients.
• Indications: include symptomatic heart failure, asymptomatic left ventricular or systemic
ventricular dysfunction, hypertension and systemic semilunar or atrioventricular valve
regurgitation.
• Side Effects: include hypotension, hyperkalemia, angioedema, dizziness, syncope,
anemia, and cough.
• Special Considerations: Patients should have a recent serum K+ and Cr prior to
starting an ACE-I; follow up serum K+ and Cr should be obtained after starting an ACE-I,
timing should depend upon the clinical situation; initiation of ACE-I in unstable,
hospitalized patient will preferably be done with captopril.
Angiotensin Receptor Blockers
Angiotensin receptor blockers (ARBs) have a mechanism of action similar to the ACE-inhibitors
and have been shown to have similar effects on adult heart failure but there is limited pediatric
heart failure data on ARBs. Losartan is the most frequently used. Valsartan is a component of
Entresto but can be used alone.
• Indications: ARBs are similar to ACE-inhibitors and are typically used when a patient is
not able to tolerate an ACE-inhibitor (typically for cough).
• Side Effects: include hypotension, angioedema, dizziness, syncope & anemia.
Updated 7/31/2018 page 8